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7001 Wild Mushroom Verification Form

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7001 Wild Mushroom Verification Form North Carolina Wild Mushroom Verification Form Date: ______________ Establishment ID#: _________________________ Tag #:__________________ Name of Establishment: _________________________________________________________________ Address: _____________________________________________________________________________ City: ___________________________ State: _________________ Zip Code: _________________ Person in Charge (PIC): __________________________________________________________________ Name of Forager: ______________________________________________________________________ Address: _____________________________________________________________________________ City: ___________________________ State: _________________ Zip Code: _________________ Email Address: _____________________________________ Phone: ___________________________ List of the common and scientific name of each wild mushroom species sold this date: Example: Chanterelle (Cantharellus cibarius, lateritius, appalachiensis) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ NOTE: Mushrooms must be identified in the wild, fresh state (not processed, dried, or cultivated). Provide a statement as to the qualifications and training of the wild mushroom forager, specifically related to mushroom identification: _______________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ North Carolina Food Code Manual, 3-201.16 Wild Mushrooms (A) Except as specified in ¶ (B) of this section, mushroom species picked in the wild shall be obtained from sources where each mushroom is individually inspected and found to be safe by an APPROVED mushroom identification expert. (B) This section does not apply to: (1) Cultivated wild mushrooms species that are grown, harvested, and processed in an operation that is regulated by the food regulatory agency that has jurisdiction over the operation; or (2) Wild mushrooms species if they are in packaged form and are the product of a food processing plant that is regulated by the food regulatory agency that has jurisdiction over the plant. The food establishment that prepares, sells, and serves mushrooms picked in the wild shall ensure the mushrooms are identified by a label, placard, or menu notation that states the common name of the wild mushroom. This document must remain on file in the food establishment for a minimum of 90 days from the date of sale of the wild mushrooms. I attest to the accuracy of the information provided in this Wild Mushroom Buyer Verification. Signature of Forager:________________________________________ Date: ______________________ Signature of PIC: ___________________________________________ Date: _______________________ North Carolina Department of Health & Human Services / Division of Public Health / Environmental Health Section / Food Protection Program 5605 Six Forks Rd. / 1632 Mail Service Center / Raleigh, NC 27699-1632 919 707 5854 May 2017 .
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